Giddiness and Dizziness

• Vertigo: visualized spinning of the environment (website)
  
• 2 types of Dizziness
  1) non specific symptom = systemic? eg VITS (VS, Infectious, Toxic Metab, Structural)
  dizziness = vague, inconsistent, or unreliable [Mayo Clin Proc 2007;82(11):1329–40]
  2) specific dizziness = peripheral vertigo vs central vertigo
  
  
• 3 Types [Emerg Med Clin N Am 27 (2009) 39–50]
  1) Acute Severe: Vestibular Neuritis vs Stroke
  2) Recurrent Positional: BPPV vs Cerebellar Tumor/Chiari Malformation/Degenerative Ataxia
  3) Recurrent Attacks: Meniere's vs TIA
  
  

1) Acute Severe: (Vestibular Neuritis vs Stroke)
think stroke if focal numbness, focal weakness, slurred speech

• Symptoms: sudden, severe, constant dizziness; N/V; imbalance
  
  
• Peripheral Vestibular Signs:
  1) Unidirectional or horizontal spontaneous nystagmus
  2) Head-thrust test + (video mov)
  
• CNS Signs
  1) Bidirectional or down-beat gaze-evoked nystagmus
  2) Severe imbalance

2) Recurrent Positional: (BPPV vs Chiari Malformation, Cerebellar tumor, Deg ataxia)

• symptoms: dizziness attacks triggered by head movement
  * DDx: orthostatic hypotension
  
  
• PV signs:
  1) attacks last less than 1 minute. Normal between attacks
  2) Dix-Hallpike/Nylen-Barany test: Burst of upbeat torsional/rotational nystagmus (video emrap.tv)
  3) Epley maneuver: resolution of signs and symptoms
  
• CNS signs:
  1) attacks can be short or long duration. Less severe dizziness between attacks
  2) Dix-Hallpike test: Persistent down-beating nystagmus or pure torsional/rotational nystagmus
  3) Epley maneuver: no effect

3) Recurrent Attacks: (Meniere's vs TIA)

• symptoms: spontaneous attacks of dizziness
  
  
• PV signs: >20 minutes to hours; with
  1. Hearing loss, unilateral
  2. Tinnitus, roaring
  3. Ear fullness
• CNS signs: minutes in duration
  new onset and crescendo pattern
  

HOW TO:
A. Head Thrust Test: (vs Head Shake test)
1. Place hands to sides of face
2. Ask patient to fixate on your nose
3. Tell patient that you will rapidly move head to one side but keeps eye on nose
4. Rapidly thrust head about 20 degrees to either side
5. (-) Eye still fixated; (+) Eye falls off target but makes a corrective saccade

B. Dix-Hallpike: determine which side gives vertigo
1. Patient sitting with leg extended
2. Tell patient that you will rapidly lower his head (edge of bed/pillow at the back)
3. Hold patient's head at 45 deg of side and rapidly lower head till 20 deg below level
= maintain for 1-2 minutes (there is about 10 seconds latency before nystagmus is seen)
(+) upbeat rotational/tortional nystagmus = PERIPHERAL
(+) downbeat rotational or pure rotational = CENTRAL
(-) no nystagmus

C. Epley Maneuver
1. Dix-Hallpike Position
2. Turn head 90 degrees to the opposite side (normal side) = 1-2 minutes
3. Turn head another 90 degrees downward (patient's body is now in lateral decubitus)
4. 4th position: ask patient to bend legs and dangle at the edge of the bed, sit patient down

D. Summary of tests done in Vertigo patient

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Dizziness Questions
1. Focal numbness/weakness/slurred speech
2. First time? (vestibular neuritis vs Stroke)
3. Head movement? ( BPPV vs CCD)
4. Ear symptoms (HTE: Hearing loss, tinnitus, ear fullness)
5. Sudden? Severe? Duration?

PE
1. Nystagmus, spontaneous
2. Nystagmus, gaze-evoked
3. Smooth pursuit
4. Saccade

5. Head Thrust Test
6. Dix-Hallpike
7. Epley Maneuver
8. Neuro exam